Arlington Family Chiropractic
20218 77th Ave NE Suite A
Suite A
Arlington, WA 98223

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information
Contact Information
Feet Inches

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)


Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

Employment Information

Current Symptoms

If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?

Insurance & Payment for Care

Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History

Family/Primary Physician

Separate details with "," comma as shown above.

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Personal Incident History:

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Family Health History

Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

Social History & Life Choices:


Chiropractic Experience

Please select all that apply.


If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

For Women Only


Health Problems & Concerns:

Please select all that you have had or currently have.

Electronic Health Record (EHR) Information

Preferred Language: Ethnicity:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered


INFORMED CONSENT FOR CHIROPRACTIC TREATMENT. I hereby request and consent to the performance of chiropractic treatments (also chiropractic adjustments or chiropractic manipulative treatments) and any other associated procedures: physical examination, tests, diagnostic x-rays, physio-therapy, physical medicine, physical therapy procedures, etc. on me by the doctor of chiropractic named above and/or other assistants and/or licensed practitioners.I understand, as with any health care procedures, that there are certain complications, which may arise during chiropractic treatments. Those complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, Homers’ syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, that are in my best interest. I have had an opportunity to discuss the nature, purpose and risks of chiropractic treatments and other recommended procedures. I have had my questions answered to my satisfaction. I also understand that specific results are not guaranteed. If there is any dispute about my care, I agree to a resolution by binding arbitration according to the American Arbitration Association guidelines.I have read (or have had read to me) the above explanation of the chiropractic treatments. I state that I have been informed and weighed the risks involved in chiropractic treatment at this health care office. I have decided that it is in my best interest to receive chiropractic treatment. I hereby give my consent to that treatment. I intend for this consent to cover the entire course of treatment for my present condition(s) and for any future conditions(s) for which I seek treatment.I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. PLEASE SIGN TO SHOW YOU UNDERSTAND AND AGREE TO THE ABOVE. FIRST: CHECK THE BOX BELOW IN THE LOWER LEFT AND SIGN IN THE BOX...YOU MUST PRESS AND HOLD THE LEFT MOUSE BUTTON WHILE MOVING THE MOUSE AS YOU WRITE YOUR SIGNATURE!!!

Name of the Insured:
(Please Print)
Patient's/Guardian's signature:


Finalizing Form

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